A nurse is collecting data from a client. The provider suspects the client may have the syndrome of inappropriate antidiuretic hormone (SIADH). When obtaining a medical history, the nurse should ask for additional information about which of the following conditions? (Select all that apply.)

Osteoarthritis

Lung cancer

Liver cirrhosis

Dyspepsia

Seizures

Answer and Explanation

Correct Answer : B,C,E

Choice A reason: Osteoarthritis is a degenerative joint disease and is not associated with SIADH. It does not typically affect the body's regulation of antidiuretic hormone (ADH) or fluid balance.

Choice B reason: Lung cancer, particularly small cell lung cancer, is a common cause of SIADH. Tumor cells can produce and secrete ADH, leading to inappropriate water retention and hyponatremia. Therefore, asking about lung cancer history is important in the assessment.

Choice C reason: The correct answer is c because liver cirrhosis can lead to secondary conditions that may affect fluid balance and ADH secretion. Although not a direct cause of SIADH, liver dysfunction can complicate the clinical picture and contribute to fluid retention issues.

Choice D reason: Dyspepsia, or indigestion, is not related to SIADH and does not typically impact ADH regulation. It is a gastrointestinal issue that does not affect fluid balance.

Choice E reason: The correct answer is e because seizures can be associated with conditions that trigger SIADH. Neurological disorders, including brain injuries and infections, can lead to the inappropriate release of ADH, resulting in fluid retention and hyponatremia.

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Correct Answer is C

Explanation

Choice A reason: Lactulose is a laxative used to treat constipation and hepatic encephalopathy by reducing blood ammonia levels, but it is not effective in lowering serum potassium levels. Therefore, it would not be the appropriate medication for treating hyperkalemia.

Choice B reason: Triamterene is a potassium-sparing diuretic, which means it helps the body retain potassium. Administering Triamterene in a client with high potassium levels (hyperkalemia) would exacerbate the condition rather than improve it. Hence, it is not a suitable choice for this scenario.

Choice C reason: Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia by binding to potassium in the intestines and facilitating its removal from the body through feces. It effectively reduces serum potassium levels, making it the appropriate medication for a client with hyperkalemia.

Choice D reason: Acetylcysteine is used primarily as a mucolytic agent to break down mucus in the airways or as an antidote for acetaminophen (paracetamol) overdose. It does not have any effect on serum potassium levels and is not suitable for treating hyperkalemia.

A. Massage erythematous bony prominences. B. Implement a turning schedule every 4 hr. C. Use pillows to keep heels off the bed surface. D. Keep environmental humidity less than 30%. E. Minimize skin exposure to moisture.

Correct Answer is ["C","E"]

Explanation

Choice A reason: Massaging erythematous bony prominences can actually cause further damage to the skin and underlying tissues. It is better to relieve pressure and monitor the skin closely for any signs of breakdown.

Choice B reason: Implementing a turning schedule every 4 hours is not frequent enough. Clients with spinal cord injuries should be repositioned every 2 hours to prevent prolonged pressure on any one area and reduce the risk of skin breakdown.

Choice C reason: The correct answer is c because using pillows to keep the heels off the bed surface helps prevent pressure ulcers on the heels, which are common sites of skin breakdown in immobilized clients. This technique helps distribute pressure more evenly and reduces the risk of ulcers.

Choice D reason: Keeping environmental humidity less than 30% is not recommended, as low humidity can lead to dry and cracked skin, increasing the risk of skin breakdown. Maintaining a moderate humidity level helps keep the skin hydrated and intact.

Choice E reason: The correct answer is e because minimizing skin exposure to moisture, such as sweat, urine, or wound exudate, helps prevent maceration and skin breakdown. Using moisture-wicking materials and keeping the skin dry and clean are important measures in skin care for paralyzed clients.

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A nurse is collecting data from a client. The provider suspects the client may have the syndrome of inappropriate antidiuretic hormone (SIADH). When obtaining a medical history, the nurse should ask for additional information about which of the following conditions? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client and identifies a serum potassium of 6.8 mEq/L. Which of the following medications should the nurse expect to administer?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who has a spinal cord injury and paralysis. Which of the following actions should the nurse include in the plan to decrease the client’s risk of skin breakdown? (Select all that apply.)

Correct Answer is ["C","E"]

Explanation

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